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KHATUNA NIHAS
3037 154th St # 1
Flushing, NY 11354-2411
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September 22, 2020
Account ID: AC0007579604

IMPORTANT NOTICE
ABOUT YOUR PLAN ENROLLMENT

Dear KHATUNA NIHAS,

This notice concerns your health insurance through NY State of Health as of September 21, 2020.

If any of the enrollment information listed below is not correct, please call us right away.

ENROLLED IN A MEDICAID Plan Name: Fidelis Care

PLAN: Insurance Company: Fidelis Care
Plan Type: Medical with Dental
Member(s) Coverage Information

KHATUNA NIHAS Your Premium: $0 (free) per month

Marketplace ID: HX0002502292 Enrollment Start Date: September 01, 2018
CIN: YM50689T
T012-76554154-01

Call NY State of Health at 1-855-355-5777 (TTY: 1-800-662-1220) to get help in other languages or for help
reading this notice. This notice is also available in other formats. Call for more information. To find a
navigator or certified application assistor near you, visit https://www.nystateofhealth.ny.gov or call us.
For questions about what services and health care providers are covered, please call your insurance
company at:

Fidelis Care 1-888-343-3547

TTY: 711

Information About Ending or Changing Your Coverage through NY State of Health

Ending Your Coverage

You can end your coverage through NY State of Health at any time. You can end coverage through NY
State of Health for yourself, for everybody in your household or just for some household members. Call
NY State of Health at 1-855-355-5777 to learn more about ending your coverage.

Important Things to Consider When Ending Your Coverage:

o Ending Your Qualified Health Plan: If you end coverage for you or another person, you may not
re-enroll until the next annual Open Enrollment period. This rule does not apply if you qualify for
a Special Enrollment period (SEP). Life events that open an SEP include getting married or
having a baby. For more information about SEPs, visit
http://info.nystateofhealth.ny.gov/SpecialEnrollmentPeriods.

IMPORTANT: When you end coverage with one plan and start a new one in the same year, all
of your cost-sharing responsibilities start over. For example, any payments that went toward the
annual deductible for your old plan will not apply to the new plan. This is true even if the new
plan is with the same company.

o Ending Your Medicaid, Child Health Plus, Essential Plan, or Qualified Health Plan: You will no
longer be able to access services after your coverage ends.

Please Note: Changing your coverage is different than ending your coverage. If you want to switch
plans and do not want to make any other changes to your account, call NY State of Health to find out if
you are eligible to switch plans and to pick a different plan. Enrollment in Child Health Plus and the
Essential Plan can be changed at any time during the year.

If anything has changed in your life that might affect how you are covered and what you pay for health
insurance, you must go to http://www.nystateofhealth.ny.gov. Log into your account to update your
application with any changes about you or your household members. The types of changes that may
affect your eligibility can be found in section, “Reporting changes during the year,” of this notice.

Reporting Changes during the year

Over the next year, you are obligated to report to NY State of Health any changes that would affect
your eligibility for enrollment in health insurance within 30 days of such a change. You need to tell us if:

– You move;

– Your income changes (only if you are receiving financial assistance);

T012-76554154-01

– Your eligibility for health insurance from a job changes;

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 – Your household changes, for example, you marry/divorce, become pregnant, or have a
child(ren); adopt a child(ren) or if a child(ren) is placed for adoption with you;

– You become qualified for other insurance;

– Change in full-time student status (if applicable to application members);

– Change in immigration status;

– Change how you plan to file your taxes, for example, if you will claim new dependents (only
if you are receiving financial assistance).

To report changes you may go to your My Account at www.nystateofhealth.ny.gov or contact us. If you
do not report changes, and the changes affect your eligibility for advance premium tax credits, you may
have to pay back some or all of the subsidies you received.

Additional Information about Medicaid

Next Steps for health plan enrollment in Medicaid:

If you are eligible to enroll in a Medicaid Managed Care plan and are not yet enrolled in one, you need
to choose a health plan. If you do not choose a plan, one will be chosen for you. If you need health
care before your health plan coverage begins, use your Medicaid card at any health provider who takes
Medicaid.

– Your new health plan card will come in the mail.

– If you are enrolled in a Medicaid Managed Care plan, you will get two cards – a New York
State Benefit Identification card (Medicaid card) and a card from your health plan. Keep
your health plan card and Medicaid card in a safe place; you will need both.

– You must use Medicaid providers and show your Medicaid card to receive any Medicaid
services that are not covered by your Managed Care plan.

– You will receive information about your benefits and available providers in your network from
your plan. The benefit package will cover a wide range of services, including doctor’s visits,
inpatient hospital care, lab tests, prescription and non-prescription drugs and much more.
For any questions about your health plan’s covered services and providers, you may contact
your health plan directly.

– You should contact your new health plan to select your Primary Care Provider (PCP). If you
are choosing a new doctor, call the doctor’s office first to make sure that he or she is
accepting new patients and is participating in the health plan you have selected.

– You may have the opportunity to opt out of enrolling into a Medicaid Managed Care plan.
Some people have a special situation that allows them to choose to either join a health plan
T012-76554154-01

or to receive regular (fee-for-service) Medicaid. This includes Native Americans, and people
in waivered programs such as Care At Home and Traumatic Brain Injury (TBI). If you think

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 you may have one of these special situations, or would like to learn more about your
options, you may call NY State of Health.

– You may be eligible to select and enroll in a Special Needs Plan (SNP) if you are a New
York City health plan member. SNPs, with their own set of doctors, providers, and hospitals,
are designed to meet the specialized health needs of individuals who are homeless,
transgender, or living with HIV/AIDS. Medicaid members who are eligible for SNP may
transfer to these plans at any time.

– You may be eligible to select and enroll in a Health and Recovery Plan (HARP) for adults
who need physical and/or behavioral health services. HARPs provide services such as
doctor visits, mental health and substance use disorder services, medications, and hospital
care. Medicaid members who are eligible for HARP may transfer to these plans at any time.

– Persons eligible for HARP or SNP can transfer into these plans at any time. For persons
eligible for all other plans, you will have 90 days from the effective date of your health plan
enrollment to change your plan for any reason. You can only change plans if there is
another health plan available in your area. After 90 days, you will not be able to change your
health plan for the next 9 months, unless you have a good reason. For more information
about this, contact NY State of Health.

Important information about your New York State Benefit Identification card (Medicaid card):

If you are new to the Medicaid program, you will receive a New York State Benefit Identification card
(Medicaid card) in the mail. If you received Medicaid benefits in the past and were issued a card at that
time, you should use that card. Please call NY State of Health at 1-855-355-5777 if you do not get your
card or cannot find your old card.

You must bring your card with you each time you use medical services. Please keep your card in a safe
place and let us know immediately if your card does not work, is lost or stolen. Keep this card even if
you stop receiving benefits. The same card may be used again if you become eligible in the future.

If you need medical care before you receive your card, you must make sure the provider accepts
Medicaid. The Medicaid program can only pay the bill for medical services if the provider accepts
Medicaid.

For more information on what services are covered by Medicaid or to find a Medicaid provider near you,
please call the Medicaid Helpline at 1-800-541-2831.

How to Contact NY State of Health

Contact us if you have any questions about this Notice. Let us know if you need help applying for or
accessing your health insurance coverage.

– Call: 1-855-355-5777 (TTY: 1-800-662-1220)

– Mail: NY State of Health

PO Box 11727
Albany, New York 12211
T012-76554154-01

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Sincerely,

NY State of Health, The Official Health Plan Marketplace.

Legal Reference:

Listed below are the specific laws and government regulations which give NY State of Health the
authority and which set the rules under which we can offer affordable health insurance to New York
State residents.

Eligibility standards for enrollment through NY State of Health may be found at 45 CFR §155.305.

This decision is based on Section 364-j of the Social Services Law.

GO PAPERLESS

Make managing your account easier by going paperless. By going paperless, all of your important
notices will be in one secure place and you can read your notices online at any time. We will send you
an email alert when a new notice is available to read on your NY State of Health account. You must log
into your account to view your notices. We will not include any private or confidential information in the
email.

If you want to go paperless, log into your account and click on “Edit Account Information.” Under
“Communication Preferences”, choose “Paperless” to get email alerts when new notices are posted to
your NY State of Health account. You have the option to change this selection at any time.

It is important your address is correct in your account. Make sure that NY State of Health has your
current mailing and residential address. Coverage for you or your family may be impacted if we do not
have your current address.

Health Insurance Portability and Accountability Act (HIPAA)

New York State is committed to protecting your privacy. To learn more about NY State of Health's
privacy practices go to www.nystateofhealth.ny.gov or call customer service at 1-855-355-5777 (TTY:
1-800-662-1220).

Notice of Nondiscrimination Policy

NY State of Health complies with applicable Federal civil rights laws and state laws and does not
discriminate on the basis of race, color, national origin, creed/religion, sex, age, marital/family status,
disability, arrest record, criminal conviction(s), gender identity, sexual orientation, predisposing genetic
characteristics, military status, domestic violence victim status and/or retaliation.

If you believe that NY State of Health has discriminated against you, you may file a complaint by going
to: www.health.ny.gov/regulations/discrimination_complaints/ or by emailing the Diversity Management
Office at DMO@health.ny.gov.

You may also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights electronically at https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf or by mail or
phone at U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room
509F, HHH Building, Washington, D.C. 20201; 1-800-368-1019 (TTY: 1-800-537-7697). Complaint
T012-76554154-01

forms are available at www.hhs.gov/ocr/office/file/index.html.

Accommodations

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NY State of Health provides free aids and services to people with disabilities to communicate effectively
with us, such as:

– TTY through New York Relay Service

– If you are blind or seriously visually impaired and need notices or other written materials in an
alternative format (large print, audio or data CD, or Braille), contact 1-855-355-5777 (TTY:
1-800-662-1220).

NY State of Health also provides free language assistance services to people whose primary language
is not English, such as:

– Qualified interpreters

– Written information in other languages

If you need these services or for more information on Reasonable Accommodations, please call
1-855-355-5777 (TTY: 1-800-662-1220).

T012-76554154-01

6 of 6
Getting Help in a Language Other than English
This is an important document. If you need help to understand it, please call 1-855-355-5777. We can
give you an interpreter for free in the language you speak.

Español (Spanish)
Este es un documento importante. Si necesita ayuda para entenderlo, llame al 1-855-355-5777.
Podemos proporcionarle gratuitamente un intérprete en el idioma que habla.

繁體中文 (Traditional Chinese)

這是一份重要文件。如果您在理解這份文件上需要幫助，請撥打電話：1-855-355-5777。 我們可為您免費
提供一名會講您的語言的口譯人員。

简体中文 (Simplified Chinese)

这是一份重要文件。如果您在理解这份文件上需要帮助，请拨打电话：1-855-355-5777。 我们可为您免费
提供一名会讲您的语言的口译人员。

Русский (Russian)
Это важный документ. Если вам нужна помощь, чтобы понять его, позвоните по телефону
1-855-355-5777. Мы можем бесплатно предоставить вам переводчика на ваш родной язык.

Kreyòl Ayisyen (Haitian Creole)

Sa a se yon dokiman enpòtan. Si ou bezwen èd pou w konprann li, tanpri rele 1-855-355-5777. Nou ka
ba ou yon entèprèt gratis nan lang ou pale a.

বাংলা (Bengali)
এ􀎜ট এক􀎜 ট গু রু ত্ব
পূণ নিথ।
􀎺 যিদ এ􀎜 ট বুঝেত আপনার সাহােয􀒝
র প্রেয়াজন হয় তেব অনুগ্রহ কের 1-855-355-5777
এ কল করু ন। আপিন 􀎭 য ভাষায় কথা বেলন আমরা আপনােক িবনামূেল􀒝 􀎭স ভাষায় 􀎭
দাভাষী প্রদান করেত পাির।

(Arabic) ‫اﻟﻠﻐﺔ اﻟﻌﺮﺑﻴﺔ‬

‫ وﻳﻤﻜﻨﻨﺎ أن‬.1-855-355-5777 ‫ ﻳُﺮﺟﻰ اﻻﺗﺼﺎل ﻋﻠﻰ اﻟﺮﻗﻢ‬،‫ وإذا ﻛﻨﺖ ﺑﺤﺎﺟﺔ إﻟﻰ ﻣﺴﺎﻋﺪة ﻟﻔﻬﻢ اﻟﻮﺛﻴﻘﺔ‬.‫ﻫﺬه اﻟﻮﺛﻴﻘﺔ ﻣﻬﻤﺔ‬
.‫ﻧﻮﻓﺮ ﻟﻚ ﻣﺘﺮﺟﻤًﺎ ﻓﻮرﻳًﺎ ﺑﺎﻟﻠﻐﺔ اﻟﺘﻲ ﺗﺘﺤﺪﺛﻬﺎ ﻣﺠﺎﻧًﺎ‬

한국어 (Korean)
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언어의 무료 통역사를 제공해드릴 수 있습니다.

Français (French)
Ceci est un document important. Si vous avez besoin d’aide pour le comprendre, appelez le
1-855-355-5777. Nous pouvons vous offrir gratuitement les services d’un interprète qui parle votre
langue.

Polski (Polish)
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numer 1-855-355-5777. Możemy zapewnić bezpłatne usługi tłumacza w Pana(i) języku.

􁤖
हन्
दी (Hindi)
यह एक महत्वपूण􁭅
दस्
तावेज है। य􁳰
द आपको इसे समझने के िलए सहायता क􁳱आवश् यकता हो, तो कृ पया 1-855-355-5777 पर
कॉल कर􁱶। हम आपको आप जो भाषा (􁳲हदी) बोलते ह􁱹
उसम􁱶 िनःशुल्
क दुभािषया सेवा प्रदान कर सकते ह􁱹
।
 (Urdu) ‫اردو‬
‫ﭘﺮ ﮐﺎل ﮐﺮﯾﮟ۔ ﮨﻢ آپ ﮐﻮ‬1-855-355-5777 ‫ ﺗﻮ ﺑﺮاﮦِ ﮐﺮم‬،‫ﯾہ اﮨﻢ دﺳﺘﺎوﯾﺰ ﮨﮯ۔ اﮔﺮ آپ ﮐﻮ اﺳﮯ ﺳﻤﺠﮭﻨﮯ ﻣﯿﮟ ﻣﺪد درﮐﺎر ﮨﮯ‬
‫آپ ﮐﯽ زﺑﺎن ﻣﯿﮟ ﻣُﻔﺖ ﺗﺮﺟﻤﺎن ﻓﺮاﮨﻢ ﮐﺮ ﺳﮑﺘﮯ ﮨﯿﮟ۔‬

shqip (Albanian)
Ky është një dokument i rëndësishëm. Nëse ju nevojitet ndihmë për ta kuptuar, lutemi merrni në telefoni
në 1-855-355-5777. Mund t'ju caktojmë një përkthyes pa pagesë, në gjuhën në të cilën ju flisni.

नेपाली (Nepali)
यो एउटा महत्त्वपूण􁭅
कागजात हो। यसलाई बुझ् न तपाईंलाई मद्दत चािहन्
छ भने, कृ पया 1-855-355-5777 मा फोन गनु􁭅
होस्। हामीले
तपाईंले बोल्
ने भाषामा तपाईंलाई िन:शुल्
क दोभाषे उपलब्
ध गराउन सक्छ􁲅 ।

Tiếng Việt (Vietnamese)

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Italiano (Italian)
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1-855-355-5777. Possiamo fornirle gratuitamente un interprete per la lingua da lei parlata.

日本語 (Japanese)
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客様のお話しになる言語の通訳を無料でお付け致します。

Ελληνικά (Greek)
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1-855-355-5777. Μπορούμε να σας παρέχουμε δωρεάν διερμηνέα στη γλώσσα που μιλάτε.

Tagalog (Tagalog)
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tawagan ang 1-855-355-5777. Maaari ka naming bigyan ng isang interpreter ng libre sa (Tagalog) wika
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(Yiddish) ‫אידיש‬
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.‫דמיר קענען אייך געבן א דאלמעטשער אומזיסט אינעם שפראך וואס איר רמיר‬

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Tunaweza kukupa mkalimani bila malipo kwa lugha unayozungumza.

Akan kasa (Twi)

Wei yɛ nhomaa ɛho sombo. Sɛ wobɛ hia mboa de ateasie a, yɛ srɛ frɛ 1-855-355-5777. Yɛ bɛ tumi ama
wo nkyerɛkyerɛmuni a yɛn gye ho hwee wɔ kasa wo ka mu.